Acute Coronary Syndromes w/out Persistent ST-Segment Elevation Initial Assessment

Clinical Presentation

Ischemic-type Chest Discomfort or Anginal Equivalent  

Retrosternal chest pain is pain that is usually described as heaviness, pressure, tightness, cramping or burning in nature. It may occur at rest or during activity that may be associated with physical exertion or emotional stress. Pain that is usually central or in the left chest may radiate to the jaw, left or both arms, back or shoulder. Accompanying symptoms of ischemic-type chest discomfort may include nausea and vomiting, dyspnea, diaphoresis, lightheadedness, abdominal (epigastric) pain, dizziness, fatigue, weakness and loss of consciousness.  

Chest pain-equivalent symptoms include pain that develops in the arm, shoulder, wrist, jaw or back without occurrence in the chest. This discomfort presents solely as jaw, neck, ear, arm, or epigastric pain and is associated with exertion or stress or is relieved promptly with Glyceryl trinitrate (GTN) should be considered equivalent to angina.  

The pain in ischemic-type chest discomfort is usually not relieved by rest or GTN. Established risk factors include smoking, dyslipidemia, hypertension, diabetes, and history of coronary artery disease (CAD).  

Please see the discussion on Evaluation for Risk Stratification. 

Acute Coronary Syndromes w.out Persistent ST-Segment Elevation_Intial Assesment

• Rest angina: Angina occurring at rest and prolonged, usually >20 minutes
• New-onset severe angina: Patient usually has marked limitation on ordinary physical activity (angina occurs on walking one to two blocks on level or climbing one flight of stairs under normal conditions and at a normal pace)
• Increasing or crescendo angina: Previously diagnosed effort-related angina that has become distinctly more frequent, longer in duration or more easily provoked (by less effort than before)
• Post-MI angina

Physical Examination

The major objectives of doing a physical examination in patients suspected with ACS is to identify precipitating causes (eg uncontrolled hypertension, thyrotoxicosis, gastrointestinal [GI] bleeding) and comorbid conditions (eg lung disease or cancer), to identify very high-risk and high-risk ACS features, to assess the hemodynamic impact of the ischemic event, to exclude non-cardiac causes of chest pain (eg pneumothorax, pulmonary embolism, pneumonia, pleural effusion, esophageal discomfort, gallstones, pancreatitis, or musculoskeletal origin), and to assess for non-ischemic cardiac disorders (eg pericarditis, valvular disease, aortic dissection, acute pericarditis, cardiac tamponade).  

Vital signs are also measured (eg blood pressure [BP] in both arms, heart rate [HR], respiratory rate [RR], and temperature). A thorough cardiovascular and chest exam are also performed which includes auscultation of the heart, neck veins, liver, and peripheral pulses to check for murmurs, bruits or pulse deficits which signify severe underlying CAD. Left ventricle (LV) dysfunction and shock should be suspected if the patient has cold extremities, hypotension, pulmonary rales, S3 gallop, displaced apex beat or S1<S2 at the apex. Aortic dissection may be present if there is pain in the back, unequal pulses, or a murmur of aortic regurgitation. While acute pericarditis is suspected by a presence of pericardial friction rub. Cardiac tamponade may be present as pulsus paradoxus.  

Patients with pneumothorax may have acute dyspnea, pleuritic chest pain, and differential breath sounds. Lastly, chest pain caused by musculoskeletal chest wall syndromes may be found by performing palpation of the chest wall. 

Diagnosis or Diagnostic Criteria

Diagnosis and initial short-term risk stratification of ACS should be based on clinical history, symptoms, vital signs, and other physical findings, electrocardiogram (ECG) results, and concentration of high-sensitivity cardiac troponin (hs-cTn). It is important that patients with suspected ACS must be evaluated quickly.